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Menopause management

Last updated 26 September 2016 — Last reviewed 02 March 2014

Management and treatment of menopausal symptoms depends on each individual woman. Healthy living, natural and complementary therapies including herbs and phytoestrogens, hormone replacement therapy (HRT), some antidepressant medications and medications typically used for high blood pressure may assist with menopause symptoms. 'Bioidentical' hormone therapy is also discussed.

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Many women cope with mild menopause symptoms and don't need to take any medication or use therapies. Some women manage their symptoms well with lifestyle measures like eating well and getting regular physical activity. Others women with symptoms that are affecting their quality of life will need to seek treatment to help them manage.

Menopause is a different experience for all women and there is a range of management options available for the different symptoms including:

Healthy living

Hormone replacement therapy

Treatments to manage vaginal dryness

Other prescription medications

Natural & complementary therapies

Bioidentical hormone therapy (not recommended)

Some treatments are well supported by valid scientific research; others have less evidence to support their use. It is important to have accurate and reliable information before you start on any treatment.

Healthy living

Lifestyle & menopause symptoms

Coping with menopause symptoms can be helped by healthy eating, a balanced nutritious diet, exercise and relaxation. Women who try to make their lifestyle as healthy as they can, appear to have less menopause symptoms and those symptoms are less severe. Women who are overweight may have more hot flushes than women of a healthy weight.

Women who have hot flushes and who exercise can reduce the frequency and severity of their hot flushes. You would think increasing your heart rate and sweating through exercise would make hot flushes worse, but it has the opposite effect and makes them a lot easier to handle.

Tips for dealing with hot flushes

Food and drink

Reduce your intake of:

caffeine

alcohol

spicy foods

Eat foods with phytoestrogens such as:

soy

tofu

whole grains (e.g. oats, barley, brown rice)

legumes (e.g. peas, beans, lentils)

Phytoestrogen may mimic the action of human oestrogen in some women and may help, but there is limited evidence to show their effectiveness.

Environment

Have fans or air conditioning operating wherever you can

Carry a small hand fan

Use a water facial spray

Have cool drinks available

Wear layers of clothing so you can take off what you need to when you are hot

Thinking about your environment and having practical strategies to help you cool down makes coping with hot flushes easier.

Relaxation (20 minutes per day) significantly reduces the intensity, although not the frequency, of hot flushes. Relaxation techniques also reduce tension, anxiety and depression.

Hot flush breathing technique

Practice this breathing technique every morning and every evening for 10 minutes. You need to find a quiet, private place where you can sit without distraction:

Keep your rib cage still

Use your stomach muscles to breathe air in and then out through your nose

Inhale slowly to the count of 5 seconds

Exhale for 5 seconds

Healthy weight

A healthy lifestyle during the menopause transition helps with maintaining a healthy weight, bone and heart health, which are all important for preventing disease later in life. Once women reach menopause their oestrogen levels drop, and their risk for osteoporosis and cardiovascular disease (diseases of the heart and blood vessels like stroke) increases so good nutrition is very important at this life stage.

As women age and move through menopause, the fat that used to sit around the hips moves up towards the tummy area. Younger women tend to be shaped more like a pear, and older women like an apple. This shift in weight to the tummy area increases the risk of cardiovascular disease, so it is important to try and minimise weight around the tummy area.

Trying to minimise weight gain and stay a 'healthy' weight can be difficult but there are techniques to help.

Sleeping well

Sleep problems may occur at midlife and during times of hormonal change like menopause. These include problems like insomnia where you find it difficult to go to sleep and stay asleep. Twice as many women experience insomnia compared with men.

Menopause symptoms, particularly hot flushes and night sweats, can disturb sleep and set off insomnia. The night sweats may change your usual pattern of sleep and your body learns this new pattern so the broken sleep pattern becomes the new norm.

Smoking

Women who smoke may reach menopause one to four years earlier than women who don't smoke. Women who smoke are also more likely to have menopausal hot flushes.

Giving up smoking is important because after menopause women have an increased risk of osteoporosis, heart disease and lung cancer, these conditions` all occur at higher rates in women who smoke.

Hormone replacement therapy (HRT)

What is hormone replacement therapy (HRT)?

The three hormones of particular relevance at menopause are oestrogen, progesterone, and testosterone. Menopausal symptoms are created by changes in the levels of these hormones. HRT, also called hormone therapy (HT), is the medical replacement of the female hormones oestrogen and progesterone and sometimes testosterone. HRT is a treatment used to help manage menopause symptoms such as hot flushes and night sweats, when they are interfering with your life.

What are the benefits of HRT?

HRT can provide relief for many of the common symptoms of menopause such as hot flushes, sweats, mood swings, irritability, insomnia, joint aches and vaginal dryness.

Types of HRT

Oestrogen and progesterone therapy

Oestrogen is the main hormone prescribed to relieve menopausal symptoms, and for women who have had a hysterectomy, this is all they may need.

In women who still have their uterus, oestrogen alone can overstimulate the cells lining the uterus causing an increased risk of endometrial cancer (cancer of the uterus).

To neutralise the risk of overstimulation, women who have not had a hysterectomy need to take progesterone or a synthetic form known as 'progestin' together with the oestrogen. 'Progestogens' is the name used to refer both to the natural form of progesterone and the synthetic form 'progestin'.

Testosterone therapy

Women experiencing loss of libido, lack of energy and ongoing fatigue, even when taking oestrogen therapy, sometimes benefit from low dose testosterone replacement. Testosterone treatment in women aims to restore levels to the typical range seen in a young woman in her early 20s.

Some studies have shown women who experience a loss of sexual interest at menopause may benefit from testosterone therapy when it is used together with oestrogen.

A study of Australian women (recruited from the community who had no complaint about their sexual function), has shown low sexual desire, arousal, responsiveness and other aspects of female sexuality are not significantly related to low testosterone levels. On the other hand, women seeking help from health professionals because they are concerned about their diminished sexual function frequently have low testosterone levels.

What are the risks of testosterone therapy?

This therapy is an area of ongoing research to better identify a safe and effective dose of testosterone for women.

Currently no form of testosterone therapy for women is officially approved in Australia by the Therapeutic Goods Administration (TGA). The TGA is a government body that assesses and monitors activities to ensure therapeutic goods available in Australia are of an acceptable standard.

Testosterone treatment in women has been associated with an increased risk of developing:

oily skin

acne

excess facial and body hair growth

scalp hair loss

irritability

aggression

Serious potential side effects include lowering of the voice and enlargement of the clitoris, both of which are irreversible.

One study of testosterone only treatment in postmenopausal women reported an increased risk of breast cancer compared to women who had received a placebo, or dummy treatment.

If you are considering testosterone therapy, talk to your doctor to gain a clear understanding of what is currently known about this therapy. It is essential for women undergoing testosterone treatment to be supervised by doctors who are experts in this area.

Tibolone or Livial

Tibolone (sold as Livial) is a synthetic hormone and its actions are similar to oestrogen, progesterone and testosterone.

Tibolone acts like

What it affects

Symptoms it assists in preventing

Oestrogen

Brain

Bones

Vaginal tissue

Flushes

Bone loss

Dryness and soreness

Progesterone

Womb/uterus

Overgrowth of the endometrium and subsequent bleeding.

Testosterone

Brain

Sexual function

Lowered mood or libido, although women's responses vary.

It may help to improve mood, help you sleep better, decrease hot flushes and improve general wellbeing. Tibolone may also help sex drive by improving vaginal secretions, increasing free testosterone and mood.

While Tibolone (Livial) is not associated with an increased risk of breast cancer, in women without breast cancer, the multinational study of women with menopause symptoms and breast cancer showed that Tibolone increased the risk of reoccurrence compared to placebo.[1]

It should also be noted that Tibolone may interfere with the effectiveness of breast cancer therapies and it is therefore not recommended for women with breast cancer.[2]

How does HRT work?

Because the symptoms of menopause, such as hot flushes and vaginal dryness, are related to fluctuating oestrogen, progesterone and sometimes testosterone levels, replacing these hormones for a period of time, helps to control these symptoms.

While there are many ways to treat hot flushes and vaginal dryness, no other treatment has been shown to be as effective as oestrogen replacement therapy[3].

How long do you take HRT?

Current guidelines recommend women who take HRT for menopausal symptoms take the lowest effective dose for the shortest time period to alleviate symptoms.

For the treatment of symptoms, women can stay on HRT for up to five years. If HRT is taken for between one to five years it is usually considered to be "short-term HRT". For many women, symptoms of menopause usually disappear within five years and short-term HRT is all that is needed. HRT should be reviewed regularly in consultation with your doctor.

If it is taken for more than five years, it is 'long-term HRT'. After five years, the need to continue should be reviewed annually and the reason for taking HRT reassessed.

In 10% of women menopausal symptoms may continue for longer than 10 years and some women have menopausal symptoms into their 60s, 70s and even 80s. These women may require HRT for symptom control for long periods. A discussion with your doctor about how to manage menopause symptoms long-term is important if this is happening to you. Some women can take HRT safely for many years but this must be assessed on an individual basis and be supported with regular reviews by a doctor.

Ways to take HRT

Pills

Oestrogen and progesterone are available separately or as combined tablets such as the contraceptive pill packs

Patches

The hormones are absorbed through the skin

Some patches contain oestrogen others are a combination of both oestrogen and progesterone

Gel

Oestrogen is available as a gel

Gel comes in single dose sachets and is used daily by rubbing into the skin daily

Creams and tablets

Creams and tablets are used locally by inserting the cream or tablet containing oestrogen into the vagina

They are mainly used by women who have vagina or bladder symptoms

Implants (No TGA approved implant is currently available in Australia)

Implants are:

about 1 centimetre long

inserted under the skin under local anaesthetic by a doctor

Intrauterine device (IUD)

A progestogen may be prescribed as an IUD.

Dosages and methods of administration vary according to each woman's needs and response to HRT. Changes may be required before a satisfactory method and dose is found for each woman, and these changes should be made under the close supervision of the doctor. It can sometimes take up to six months to find the right combination.

As a general rule when using HRT in midlife:

start low

go slow

review often

What are the risks of HRT?

Many studies have investigated whether HRT increases the risk of cancers, further illness and disease. There have been many reports in the media about the risks of HRT.

In 2002 researchers from a large study in the United States (the Women's Health Initiative trial or WHI) reported the risks of HRT outweighed the benefits of taking it. This caused an 80% drop in the use of HRT in the USA and 50% of women in Australia stopped using their HRT.

Professor Henry Burger, a founding director of Jean Hailes, says, "At least half of those women saw their symptoms return and that meant their quality of life significantly suffered" and "I think that was one of the worst consequences – the decreased quality of life and feeling that you couldn't do anything about it."

The WHI study looked at women who were many years older than the average age of menopause in Australia (51 years) and the study compared these older women who had been on HRT with women who had never been on HRT.

A recent comprehensive review of evidence on HRT has found HRT is an effective and safe treatment for the relief of menopause symptoms for healthy women.

Women who are at risk if they take HRT include those who:

have previously been diagnosed with breast or endometrial cancer

are at high risk of breast cancer or endometrial cancer

have previously been diagnosed with cardiovascular disease or had a venous thrombosis (blood clot in the vein)

are at risk of cardiovascular disease or deep vein thrombosis (including those with diabetes)

Possible side effects of HRT

You may or may not have side effects when you take HRT.

Nausea

Fluid retention

Feeling bloated

Breast enlargement and discomfort

These symptoms may be experienced when you first start taking HRT and become less with time – if they interfere with your daily life, discuss the symptom with your doctor.

Break through bleeding

Some women experience vaginal bleeding after starting HRT – in most cases this can be helped by changing the dose or type of HRT

Persistent, unexplained vaginal bleeding should be investigated

Weight gain

Most studies do not show a link between weight gain and HRT use

In several studies women who used HRT had less weight gain than those who did not use HRT

Women are prone to weight gain around the stomach in midlife (40s-50s) whether they take HRT or not

Should you take HRT?

Jean Hailes strongly advocates for women to take a balanced, evidence-based and informed approach to health – all risks and benefits should be considered when you assess whether to use HRT

Current recommendations by world experts in menopause, including our own doctors, suggest the benefits of HRT outweigh the risks for healthy menopausal women

If you choose HRT you should take the lowest effective dose for only as long as required for your symptoms and regularly review your reasons to continue (or not) with your doctor

HRT can be stopped at any time – once you've stopped treatment, any increase in breast cancer risk lessens over time and is lost within 5 years

Jean Hailes recommends each woman discuss her decision about taking HRT with her doctor regularly and whenever there are any concerns

Benefits & risks of HRT

The following table lists the benefits and risks of HRT along with conditions that still need further understanding.

Thrombosis – there is a low but increased risk of venous thrombosis (blood clots in the vein) more likely in the first year of use.

Memory.

Other benefits include improvement in:

headaches

aches and pains

irritability

sleeplessness

increased sex drive

If you are a smoker, have diabetes, high blood pressure and/or high cholesterol there is a small but increased risk in taking HRT of thrombosis.

Heart attacks in young women.

Breast cancer & HRT

For otherwise healthy women, taking HRT for 2-5 years to relieve menopausal symptoms causes little if any increase in breast cancer risk.

Chance of developing breast cancer in a given year:

If you are not taking HRT during menopause

If you take HRT for 5 years during menopause

3 in 1,000 chance

4 in 1,000

The following factors put you at a higher risk of developing breast cancer than taking HRT:

Having more than two standard alcoholic drinks per day

Being overweight or obese

Having your first child over the age of 35

Going into menopause at a later age

This risk should also be seen within the context of the benefits of HRT: it can significantly improve women's quality of life and reduce the risk of developing osteoporosis, diabetes, colon cancer and possibly heart disease.

Research and best practice guidelines suggest that menopausal women review their reasons to continue HRT (or not) with their doctor once per year, or more regularly if they have any concerns.

Lung cancer & HRT

For otherwise healthy women under 60 years of age, taking HRT for the symptoms of menopause, there is no evidence of increased lung cancer risk or of increased death from lung cancer. For women over 60 years the increased risk of lung cancer is very small.

Chance of developing lung cancer

Chance of dying from lung cancer

3 in 10,000 increased risk

5 in 10,000 increased risk

The following factors put you at a higher risk of developing lung cancer than taking HRT:

Past smoking

Current smoking

Passive smoking (inhaling smoke from others smoking around you)

Older women who are heavy smokers should not use HRT.

Cardiovascular disease & HRT

Cardiovascular disease (disease of the heart and blood vessels) is the leading cause of death in postmenopausal women. Women who are 50-59 years are generally either going through the menopausal transition or in early postmenopause. Cardiovascular disease is uncommon in this age group, but the incidence increases rapidly after 60 years.

The standard dose of HRT, usually started around the time of menopause, causes no significant increase in cardiovascular disease and may be cardio-protective.

HRT should be avoided in women who have established cardiovascular disease.

Managing vaginal problems

The loss of oestrogen at menopause causes vaginal and bladder changes that can cause symptoms such as: vaginal dryness, a dry and painful vulva, pain during intercourse and recurrent urinary tract infections.

Some of the ways you can manage these symptoms are outlined below but it is important to discuss with your doctor what is the most suitable option for you.

Dry vagina treatments

Lubricants or oil

Such as sweet almond oil or KY jelly and SYLK available over the counter.

Vaginal moisturisers

Such as Replens a low PH gel.

Black cohosh

Taken orally as well as topically (as a cream or pessary/pellet), black cohosh has been shown to be effective for vaginal dryness but more research is still needed on its effectiveness.

Linseed (flaxseed)

Linseed (flaxseed) approximately 2 tablespoons included in your diet has been shown to reduce vaginal dryness.

Hormone replacement therapy (HRT)

Is very effective in managing vagina & bladder symptoms

This can be taken in tablet, gel, or patch form

Vaginal oestrogen

Oestrogen can be applied directly to the vagina in the form of a cream, tablet or pessary

This may be the only treatment required if a woman only has vaginal symptoms

May be needed as well as HRT (or other medication) prescribed for menopausal symptoms

May be suitable for women who cannot take HRT (e.g. cardiovascular disease) – should be discussed with a doctor

Requires a prescription

Other prescription medications

Some women are not able to use hormone-based treatments for menopausal symptoms such as hot flushes and sweats including those who:

have had breast cancer

are at increased risk of getting breast cancer

have other conditions which mean they shouldn't use hormone treatments including thrombotic conditions leading to deep vein thrombosis (DVT)

Other women just prefer not to take HRT and want to look for other treatment options. Some of these prescription medications are outlined below.

Antidepressants

A group of antidepressants called SSRIs/SNRIs (selective serotonin or serotonin-norepinephrine reuptake inhibitors, for example, venlafaxine, paroxetine, sertraline, fluoxetine) have been studied and found to relieve hot flushes. If these medications are going to be effective in reducing hot flushes they will do so quite quickly. Like all medications these can have side effects, some examples are nausea, dry mouth and/or insomnia.

Clonidine

Clonidine is a medication for high blood pressure and migraine that has been shown to reduce hot flushes. Side effects may include dry mouth, dizziness and drowsiness.

Gabapentin

Gabapentin is an anticonvulsant that is also used to treat seizures and nerve pain and has been shown to diminish hot flushes. It is quite an expensive drug and side effects may include a rash, dizziness and sleepiness.

Natural & complementary therapies

Many women are keen to look for non-medical options to manage their menopausal symptoms. There is little scientific evidence that supports the effectiveness of many of these treatments and further research is still required before they can be recommended.

It is important to do some reading and investigation about treatments you are considering as they can often be expensive and unproven. It is important to see a qualified practitioner for advice and give all the health professionals you are seeing, information about any medications or treatments you are taking or receiving, as there can be interactions.

Herbal therapies and remedies for menopause

Herbal remedies, such as black cohosh and red clover, may be considered as an option for some women in the management of menopausal symptoms, such as hot flushes, night sweats and vaginal changes. It is important to note there is inconsistent research on herbal therapies and natural therapies specifically for menopause. More research on the effectiveness and safety of herbal therapies for menopause is needed.

While the effectiveness of herbal remedies will vary, herbal remedies such as St John's wort may help to manage mood changes such as anxious thoughts and depressed feelings, as well as help with fatigue and low energy. In menopause, a busy lifestyle, lack of physical activity and less than healthy eating can combine with sleeplessness to create added stress and fatigue so herbs such as valerian may be helpful.

Phytoestrogens & menopause symptoms

Phytoestrogens are compounds that occur naturally in plants (phyto) and which, under certain circumstances, show some of the same activities as the female hormone oestrogen.

Phytoestrogens are much weaker than human oestrogen, and their effects are different from the hormones found in hormone replacement therapy (HRT).

Read more about phytoestrogens and why they may be beneficial for some women going through menopause.

Other natural & complementary therapies

Research has considered other therapies for managing menopause symptoms such as:

acupuncture

traditional Chinese medicine

nutrition

remedial massage

which you may like to investigate further also.

Over the counter products

Information to consider:

Some of the herbal products available over the counter are not the same products a traditional herbalist would prescribe

The quality of some Australian-manufactured herbal medicines made for naturopaths and herbalists is considered excellent

The quality of medicines made for over the counter use may vary

The quality and source of herbal remedies purchased over the internet may be questionable

Some herbal products may contain herbs which should not be used in conjunction with pharmaceutical hormone therapies but the products may not carry this warning

Experimenting with over the counter preparations may be more costly than seeing a trained herbalist/naturopath

The best way to use herbal remedies for the treatment of symptoms at menopause is under the guidance and advice of a trained natural therapist

Bioidentical hormones & menopause

'Bioidentical' hormones are mixtures of hormones made in compounding pharmacies that are promoted as hormones 'exactly like our own' hormones. They can contain oestrogens, progesterone and sometimes other hormones like testosterone.

The hormones are made into capsules, creams, drops applied to the tongue, lozenges or troches (soft square-shaped tablets) sucked in the cheek.

Bioidentical hormones are often marketed using the term 'natural' but they are all manufactured synthetically in a process similar to the manufacture of the oral contraceptive pill, or any hormone therapy product. It is misleading to suggest these preparations have advantages over TGA (the Therapeutic Goods Administration) approved pharmaceutical oestrogen therapies.

While some women report their menopause symptoms improve using 'bioidentical' hormones this may come at a cost. Not only is this an expensive way to get hormone replacement therapy but there are real concerns over the safety and effectiveness of 'bioidentical' hormones. Currently there are no controls and regulations on the production, prescribing or dosing of bioidentical hormones.

There are questions about the safety and effectiveness of 'bioidentical' compounded hormones

We have no research evidence that the recommended doses of the hormone preparations made by compounding pharmacists are safe or effective

It has been claimed this form of hormone replacement therapy does not cause side effects. This is unproven and unlikely, with many women presenting with known complications of oestrogen and testosterone therapy while on 'bioidentical' hormonal preparations

Blood levels of hormones can be very high on troches therapy and until further research is done, women need to be cautious

There is no adequate data to show:

what dose of progestin (progesterone)

whether progesterone absorbed through the cheek

whether it protects the lining of the uterus from conditions such as endometrial (uterine) cancer

The pharmacists making the 'bioidentical' preparations are not required to adhere to the codes of conduct of the professional pharmaceutical body, Medicines Australia, as these codes apply only to pharmaceutical companies

There is limited formal quality control or quality assurance on individual formulations

Hormone formulations made in a pharmacy are expensive as they are individually prepared

Further research and regulation is needed of 'bioidentical' compounded hormones before they can be recommended for use to help with menopausal symptoms. It is important when seeking any medical treatment that you consult with a health practitioner face-to-face rather than over the phone. Receiving advice or a prescription for medication without the proper advice is not advised

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at March 2014.